Comment on CMS-2026-1916-0001

As a leader in America’s fire service, I urge CMS to modify this proposal to exempt other provider types for state-directed payments for fire-based EMS agencies and to provide additional clarity on the proposed exception for cost-reconciled payment methodologies. Fire-based EMS agencies are the backbone of emergency medical response in thousands of communities across the U.S. These agencies are responsible not only for ambulance transport but also for maintaining round-the-clock emergency response readiness; staffing paramedics on advanced life support units; and responding to cardiac arrests, strokes, myocardial infarctions, overdoses, traumatic injuries, and a wide range of medical complaints, all while ensuring surge capacity during public health emergencies and mass-casualty incidents. Unlike many other healthcare providers, fire-based EMS agencies must maintain personnel, apparatus, equipment, stations, and response capabilities regardless of patient volume, payer mix, or reimbursement levels. My fellow IAFC members operate in communities facing increasing call volumes, workforce shortages, rising personnel costs, escalating apparatus and equipment expenses, and growing demands for emergency preparedness. Supplemental Medicaid funding programs, including Ground Emergency Medical Transportation (GEMT) programs, help offset some of these costs and allow fire departments to maintain frontline emergency response capabilities. Reductions in supplemental reimbursements will force difficult operational decisions, including reducing available apparatus; delaying apparatus replacement; reducing investments in EMS equipment and technology; limiting workforce recruitment and retention efforts; and reducing the availability of advanced life support resources in underserved communities. The potential impact is particularly significant for departments that operate with limited financial flexibility while serving as the sole provider of EMS within their response area. Any reduction in funding for the existing Fee-for-Service and managed care Medicaid supplemental payment programs risks weakening local emergency response systems, reducing access to timely emergency medical care for Medicaid beneficiaries and the broader community, and undermining the quality measures these programs are currently improving. Fire-based EMS agencies serve a unique public safety role that extends far beyond transportation of Medicaid beneficiaries. These agencies maintain 24/7 emergency response readiness; provide disaster and mass-casualty response capabilities; support wildfire and all-hazards incidents; deliver emergency medical care regardless of a patient's ability to pay; and frequently serve as the primary emergency response system in their communities. Unlike traditional healthcare providers, fire-based EMS agencies must maintain personnel, vehicles, stations, equipment, and surge capacity at all times, regardless of transport volume or reimbursement levels. Fire-based EMS agencies have been at the forefront of advances in EMS care. Fire departments across the country have begun programs to treat Medicaid beneficiaries in place and avoid unnecessary and expensive hospital visits. Other agencies have begun prehospital blood transfusions, which reduce mortality, morbidity, and healthcare costs. Cuts to supplemental reimbursement programs will hinder innovation in out-of-hospital care and ultimately lead to higher costs to CMS. CMS should therefore establish a broad exemption from the proposed targeted payment limits for governmental, volunteer, and 501(c)(3) fire-based EMS agencies, including those participating in approved GEMT programs. These agencies are fundamentally different from other provider types because they perform essential public safety functions and incur significant readiness costs that are not reflected in traditional Medicare ambulance reimbursement methods. Further, CMS should provide more clarity on the proposed second exception for payments that are reconciled to actual incurred costs under §447.381(d)(2). While the proposed rule appears to recognize that cost-reconciled payment methodologies are generally consistent with economy and efficiency principles, it's unclear how CMS intends to apply this exception to GEMT programs. Fire-based EMS agencies and state Medicaid programs need clear guidance on if current GEMT payment methodologies qualify for the exception; what documentation would be required to demonstrate compliance; and if governmental providers participating in CMS-approved cost-based reimbursement programs would be considered exempt from the proposed payment limits. CMS should explicitly state that approved cost-reconciled GEMT programs satisfy the exception and provide detailed implementation guidance before finalizing the rule. Such clarification would reduce uncertainty for fire departments while helping preserve access to EMS for Medicaid beneficiaries and the communities they serve.